Percutaneous Cecostomy with Fully Covered Self-Expandable Metal Stent for Initial Management of Severe Malignant Colon Obstruction

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Percutaneous cecostomy with fully covered self-expandable metal stent for initial management of severe malignant colon obstruction

Traditionally, catheter-based percutaneous cecostomy has been utilized in the setting of closed-looped colonic obstruction and in selected patients with fecal incontinence in whom conservative management has failed. Although the procedure is associated with high rates of technical success, complications including catheter migration or dislodgement are common and occur in up to a third of patients. Catheter occlusion and leakage from the catheter site are also common, with leakage often occurring on the skin (20%) or within the perito- neum (12%) [1– 5]. Here, we explored the option of using a percutaneous, fully covered, self-expandable, metal stent (FCSEMS) for sequential decompression following malfunction of a percutaneous catheter. In theory, the caliber of the stent would allow improved drainage, while the external flange could be se- ▶ Fig.1 Positron emission tomography–computed tomography (CT) scan showing: a meta- cured with a suture, reducing the risk of static lesion at ascending colon; b dilated cecum filled with semi-solid fecal matter (arrow); migration or dislodgement. and c pneumatosis intestinalis (arrow). d CT-guided percutaneous cecostomy placement. A 44-year-old man with a complex medical history, including heart and kidney transplants and recurrent urothelial cancer, presented with colonic obstruction, secondary to metastasis from the latter, attheleveloftheascendingcolon (▶ Fig.1a). On computed tomography (CT), the cecum was dilated with solid fecal matter and demonstrated pneumatosis intestinalis of the cecal wall (▶ Fig.1b,c). As the patient was a poor This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. surgical candidate, traditional colonic stenting was considered; however, this was deemed unsuitable in view of the high risk of cecal perforation secondary to gas insufflation. Therefore, we opted for placement of a CT-guided percutaneous cecostomy tube as a temporizing measure (▶ Fig.1 d). Video 1 Percutaneous cecostomy with fully covered self-expandable metal stent for in- While technically successful, the percuta- itial management of severe malignant colon obstruction. neous cecostomy tube failed to provide significant decompression and the patient experienced both leakage onto the skin and occlusion of the catheter. Thus, we subsequently exchanged the catheter

Lim Chin Hong et al. Percutaneous cecostomy with FCSEMS for colon obstruction … Endoscopy 2017; 49: E313–E315 E313 E-Videos

▶ Fig.2 Placement of a fully covered, self-expandable, metal stent (FCSEMS). a, d Guidewire inserted through the 5Fr catheter and curled inside the cecum. b,e FCSEMS deployed under fluoroscopic and direct visualization. c,f Stent dilated with 10mm Hurricane balloon.

within the cecum (▶ Fig.2a,d). The Percutaneous cecostomy with stent catheter was removed over the guide- placement presents another minimally wire, a 1cm skin incision was made, and invasive option in the management of a 4mm balloon was used to dilate the high risk malignant colonic obstruction. tract. Over the wire an 18×60mm Niti-S This therapeutic modality should be con- esophageal stent (Taewoong Medical, sidered in appropriate high risk cases giv- Gyeonggi-do, South Korea) was de- en the potential decrease in migration, ployed, with the distal flange fully expan- dislodgement, or occlusion when com- ded inside the cecum and the proximal pared with catheter-based approaches. flange expanded outside of the abdo- men (▶ Fig.2b,e). Stool was seen ex- Endoscopy_UCTN_Code_TTT_1AT_2AZ truding out of the stent immediately after stent deployment. The stent body This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. was further dilated with a 10mm dilator Competing interests ▶ Fig.3 Colonic stent placed across the balloon (▶ Fig.2c,f)andtheproximal obstructing lesion 1 month later. flange was sutured to the skin. None The cecum was successfully decompres- sed following stent placement. The pa- foranFCSEMStoimprovedrainageand tient subsequently underwent traditional decompression (▶Video1). endoscopic colonic stent placement 1 The procedure was performed under month later (▶ Fig.3). At follow-up, he general anesthesia, and fluoroscopy was continued to have relief of his obstructive utilized throughout. A long 0.035-inch symptoms. The percutaneous stent was Jagwire (Boston Scientific, Marlborough, removed and the cecostomy was allowed Massachusetts, USA) was placed through to close spontaneously without compli- the original 5Fr catheter and curled cation.

E314 Lim Chin Hong et al. Percutaneous cecostomy with FCSEMS for colon obstruction … Endoscopy 2017; 49: E313–E315 The Authors References Bibliography DOI https://doi.org/10.1055/s-0043-119973 Published online: 9.10.2017 Chin Hong Lim1,NicholasM.McDonald2, [1] Lynch CR, Jones RG, Hilden K et al. Percuta- Endoscopy 2017; 49: E313–E315 Martin L. Freeman2,StuartK.Amateau2 neous endoscopic cecostomy in adults: a © Georg Thieme Verlag KG 1 Division of Minimally Invasive GI Surgery, case series. Gastrointest Endosc 2006; 64: 279– 282 Stuttgart · New York University of Minnesota Medical Center, [2] Marker DR, Perosi N, Ul Haq F et al. Percuta- ISSN 0013-726X Minnesota, Minneapolis, United States neous cecostomy in adult patients: safety 2 Division of Gastroenterology and and quality-of-life results. J Vasc Radiol Hepatology, University of Minnesota Medical 2015; 26: 1526– 1532 ENDOSCOPY E-VIDEOS Center, Minnesota, Minneapolis, United [3] Chait PG, Shlomovitz E, Connolly BL et al. States Percutaneous cecostomy: updates in tech- https://eref.thieme.de/e-videos nique and patient care. Radiology 2003; 227: 246– 250 Endoscopy E-Videos is a free Corresponding author [4] Donkol RH, Al-Nammi A. Percutaneous cecostomy in the management of organic fecal access online section, reporting incontinence in children. World J Radiol on interesting cases and new Stuart K. Amateau, MD 2010; 2: 463– 467 techniques in gastroenterological Interventional and Therapeutic Endoscopy, [5] Tewari SO, Getrajdman GI, Petre EN et al. endoscopy. All papers include a high Division of Gastroenterology and Safety and efficacy of percutaneous cecos- quality video and all contributions are Hepatology, University of Minnesota Medical tomy/colostomy for treatment of large Center, MMC 36-420 Delaware Street SE, bowel obstruction in adults with cancer. J freely accessible online. Minneapolis, Minnesota 55455, United Vasc Interv Radiol 2015; 26: 182– 188 States This section has its own submission Fax: +1-612-625-5620 website at [email protected] https://mc.manuscriptcentral.com/e-videos This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Lim Chin Hong et al. Percutaneous cecostomy with FCSEMS for colon obstruction … Endoscopy 2017; 49: E313–E315 E315